Veterans agency says it cannot comment on case pending investigation

An inpatient pharmacy technician supervisor at the VA Palo Alto Health Care System's Palo Alto facility said he experienced retaliation and a gag order from his superiors after speaking up about errors and delays in delivery of medication to patients.

Stuart Kallio said he was placed on administrative leave in June after writing a string of emails to his superiors, beginning on Feb. 5, that described the pharmacy as being incompetent and led by uncaring management, with consequences to patient care.

Kallio, a veteran who served nine years in the Navy, was among 800 current and former VA employees and veterans who responded to a call from the Project on Government Oversight (POGO), a nonpartisan, independent watchdog group that champions good government reforms. POGO teamed up with the Iraq and Afghanistan Veterans of America to put out a call for the stories following recent disclosures of sometimes fatal delays in treatment at VA facilities across the country.

Kallio's story was among those detailed in a July 21 POGO report titled "Fear and Retaliation at the VA."

"Until we eliminate the VA's culture of intimidation and climate of fear, no reforms will be able to turn this broken agency around," POGO Executive Director Danielle Brian said.

Palo Alto VA spokesman Michael Hill-Jackson said the agency could not comment on Kallio's case pending an investigation, which he said is underway.

"As far as any patient safety issue, we take that very seriously and if anything is brought up we investigate every single report," including any allegation Kallio made, Hill-Jackson said. He said he did not know the outcome of the investigation of any of Kallio's specific allegations.

Kallio shared with POGO a series of critical emails that he sent up the VA chain of command, eventually as high as Elizabeth (Lisa) Joyce Freeman, who served as director of the Palo Alto VA Health Care System until she left this month to become interim director of the VA's Southwest Health Care Network in Arizona.

In an email on Feb. 5, Kallio wrote to a superior, "In summation, patients are experiencing inordinate delays in their healthcare as a result of your failure and refusal to comply with VHA regulations."

On Feb. 26, he wrote, "In essence, after all these years of suffering under gross mismanagement and wonton (sic) violation of VHA regulations, the processes utilized by the Pharmacy Service have steadily deteriorated and atrophied to the point that the Inpatient Pharmacy is in reality in a perpetual state of failure, failing to provide timely, quality care to veterans."

In an April 7 letter, the chief of the pharmacy service threatened to suspend Kallio for sending a dozen emails "that contained disrespectful and inappropriate statements about your Service Chief" and others, including "VA Palo Alto Health Care System Leadership."

In a response to the chief of pharmacy service defending himself three weeks later, Kallio said that patients were suffering "missed doses, late doses, wrong doses," quoting hospital records of medication errors and copying Congressional overseers.

On May 29, the chief of pharmacy service informed Kallio he would be suspended from June 8 through June 21.

On the first day of his suspension, Kallio reiterated his complaints and accused the VA of retaliation in an email to Freeman.

"For almost two years now I have been communicating my concerns regarding the VAPAHCS Palo Alto Division Inpatient Pharmacy up the chain of command up to and including your office," he wrote. "Your response has been to unlawfully retaliate against me."

Kallio cited a case in which a patient's epidural drip of pain medication ran dry and another in which a chemotherapy drug that requires refrigeration was administered two and a half hours after its expiration and the patient developed a fever.

On June 20, the Friday before he was supposed to return to work, Kallio received notice placing him on paid administrative leave pending an investigation. The same day, he received a letter from the pharmacy service chief with the heading "Direct Order," warning him not to discuss his case "with anyone inquiring outside of official representational role or management investigative capacity and who does not have a need to know."

"As far as I am concerned, this is a public safety issue and the public has a need to know," Kallio told POGO.

Whether Kallio is right or wrong, POGO said, "punishing and trying to silence him sends precisely the wrong message for the VA. Furthermore the gag order was placed on Kallio after his VA superiors could see that he was copying Congress on correspondence; it is against the law to attempt to interfere with a person's communications with Congress."

Kallio told POGO his suspension is unpaid and he is living paycheck to paycheck, with a heavy financial and emotional toll.

Posted by EditorJean
a resident of Community Center
on Jul 22, 2014 at 11:21 amEditorJean is a registered user.

I have sad experience at the Palo Alto VA with my late husband Ralph Libby, a veteran of World War II, in 2012.

At the hospital we experienced great disrespect for his life by the doctors in charge--so much that I went to the Bioethics Committee for relief. The doctors were invariably raised in Communist countries, Russia and China, and have this devaluation in their heritage which translates into taking the veteran off medical care if he or she is terminal and sending them "upstairs" where they will be "comfortable" with morphine to end life.

We were eligible for household care assistance but placed on a permanent and terminal waiting list.

I would like to make a written statement to Congressional investigation about the Palo Alto VA. I am recovered enough from the experience (Ralph Libby passed away at home on June 17, 2012) to do so coherently.

Posted by Horrified
a resident of Another Palo Alto neighborhood
on Jul 22, 2014 at 11:36 am

In all honesty, I have to say that ALL the worst doctors I have ever had, even when I was hospitalized recently. Were doctors who had been raised in Communist countries. They seem to feel that life is cheap and expendable, especially if that life is over 45 years of age, or under one year of age. We had Kaiser for several years, and they also employ a lot of doctors from Russia and China. These doctors must work very cheaply or something, otherwise I can't for the life of me see why anyone would hire such callous people in the medical field.

Our government insisted on putting these veterans in harm's way, they owe them better than sub-standard doctors and fatally long waiting lists. This is an absolute travesty!

Posted by Elliott Sopkin
a resident of Professorville
on Jul 22, 2014 at 11:58 am

I am a Vet. I have been going to the Palo Alto facility for a good many years. I find the administrative personnel to be caring and efficient; I find the medical folk, especially my doctor, to be as good as it gets. I am well cared for  and I appreciate it.

Posted by Wayne Martin
a resident of Fairmeadow
on Jul 22, 2014 at 12:52 pm

This is a hard topic to discuss, because most of know very little about the VA, its internals, or its practices. The scope of the VA's activities is much larger than the majority of Americans are aware. One source I came across, while researching VA information suggested that as many as 25% of the American public might qualify for VA services.

The Government Accounting Office (GAO) and the VA's Inspector General (VA.IG) have been issuing reports about VA problems for years. The following is from a recent GAO report

Several weaknesses have been identified in VA and DOD programs and processes that could compromise patients' safety.

* VA did not collect and analyze aggregate data on administrative investigation boards' (AIB) investigations. These data could provide VA with valuable information to systematically gauge the extent to which matters investigated by AIBs may be occurring throughout VA's health care system and allow VA to assess the causes and take corrective action, and then share information about any improvements made as a result of the corrective actions with all VA medical facilities and networks. This could improve VA's overall operations, and in some instances, help to reduce risks to veterans' safety.

* DOD lacked a systematic process to address inconsistencies between its physician credentialing and privileging requirements and the military services' requirements. Such differences may result in military services' noncompliance with requirements that DOD deems important. Credentialing and privileging requirements help ensure that physicians who work in DOD medical facilities have the appropriate credentials and clinical competence to provide health care services to patients. Select Army facilities did not fully comply with all of the Army's physician credentialing and privileging requirements. For example, credentials files did not consistently contain documents required to support the physician's clinical competence and complete practice history. This is important in light of the Fort Hood tragedy where an Army physician allegedly shot and killed 13 people.

* VA did not review 16 percent of the total paid tort claims involving VA practitioners from fiscal years 2005 through 2010, as required by VA policy, to determine whether these practitioners delivered substandard care to veterans. Practitioners who deliver substandard care are to be reported to a national data bank that is queried by VA and non-VA hospitals as part of their hiring process and when they are deciding what privileges to grant practitioners who deliver care to patients. This requirement helps VA and non-VA hospitals to identify practitioners who may not be qualified to deliver care to patients.

* Many of the nearly 300 sexual assault incidents reported to the VA police were not reported to VA leadership officials and the VA OIG. Several factors may have contributed to this underreporting, including unclear guidance and deficiencies in VA's oversight. VA also did not have risk assessment tools designed to examine sexual assault-related risks veterans may pose. VA needs to identify and address these vulnerabilities in its medical facilities to help ensure veterans' and VA employees' safety.

* VA's training guidance for cleaning; disinfecting; and sterilizing reusable medical equipment (RME), which is designed to be used on multiple patients, has gaps and contains conflicting information. This can result in staff not cleaning; disinfecting; and sterilizing RME correctly, which poses potential risks to the safety of veterans.

---

With some web-surfing, one can find a number of studies conducted over the years that suggest that VA care is about the same as non-VA care. Unfortunately, the current VA scandal has revealed that the VA has been altering patient data, at least relative to scheduling. Moreover, it's only been with the last three years that the VA has been offering medical performance data on a hospital by hospital basisso the conclusions of the older studies about VA healthcare falls into some disrepute.

Maintaining data should be one of the most fundamental jobs of the management team. So, when the full extent of this patient data manipulation becomes knownwhat will Congress do about it?

Recently Sen. Tom Coburn has released a fairly readable report on many of the known problems at the VA:

Posted by rose gooch
a resident of Los Altos
on Jul 22, 2014 at 7:02 pm

My husband received the best care he has ever received at the VA in
Palo Alto and the VA in San Francisco. The doctors who cared for him were educated at Stanford or University of San Francisco and were first-rate. They fast-tracked him whenever he had a problem and he volunteered and was accepted for many leading edge technologies that took place at the SF and PA VAs. They carefully control substances which I applaud. His need was justified and he received what he needed, but it wasn't dispensed gratuitously.

Dear EditorJean
I am so sorry to hear about your husband's care at the PA VA. I remember him working as the best reference librarian at the Main Library. He was always there. A soft spoken and gentle man who knew where everything was. He really deserved better than he received at the VA. My condolences to you.

Posted by Peter Carpenter
a resident of Atherton
on Jul 27, 2014 at 3:24 pmPeter Carpenter is a registered user.

I have been a PA VA patient for almost 12 years and during that time I have always received the best quality of medical care from a superbly qualified and compassionate staff. Having been the Executive Director of the Stanford Medical Center I have some insights into the challenges involved in consistently providing high quality medical care - the PA VA standard of care is the best that I have ever personally experienced.

I have been a long-time, front-line employee at the VA Palo Alto. I don't know about the communist MD comments, but regardless...I am not a communist and I was born here in the USA. The front-line people there that provide hands-on patient care work very hard. I have seen various researchers and non hands-on staff over the many years that are very disappointing and uncaring. THAT is yet another problem with the VA: the only way to get fired is to say something bad about the faulty leadership or walk in and shoot somebody. Hard working clinicians must work around the mediocre staff, which is very bad for morale. Problematic staff are simply shuttled around to other departments while hard-workers just get dumped upon. Another issue which others have already brought up (other comments in here) is that the leaders indeed do alter data. Or, don't bring up or address data that is blatantly problematic. They do employee surveys that show vast employee dis-satisfaction, but only "pose" through any actions to try and address the relevant issues. There are issues indeed with retaliation when hard-working and well meaning employees bring problems up. Many that I have worked with for over 30 years have experienced this; not to the point of the pharmacy staff who is now suspended, but in subtle ways.

Posted by Worried sick
a resident of Old Palo Alto
on Jul 27, 2014 at 7:18 pm

I am worried SICK for my nephew who was a medic in Afghanistan for a year, and was also wounded and the lone survivor of an IED attack. He has seen such horrible sights of the terrible things that the Taliban perpetrate on their own people and on Americans. He is also suffering from survivor's guilt as well as PTSD. Even though wounded and hospitalized, he has amnesia about the explosion that killed his fellow passengers in the Humvee, but the Army would not discharge him, just returned him to service ASAP.

Now serving in an Army hospital in another state, the VA is supplying him with drugs, but not actual treatment. How can so done on psychoactive drugs and sleeping pills competently work in a medical capacity??? Yet, the Army just will not let him go, and he has served over three years total.

Posted by Peter Carpenter
a resident of Atherton
on Jul 28, 2014 at 10:35 amPeter Carpenter is a registered user.

I you really are "worried sick" I suggest that you encourage your nephew to post his first hand experience on this Forum and on the PA VA's Facebook page. Anecdotal second hand information is often incomplete and inaccurate.

Posted by Tip of the Iceberg Indeed
a resident of Downtown North
on Jul 29, 2014 at 8:18 pm

The VA encourages their employees to report all problems. If an employee wants to remain anonymous during the reporting process, it is possible by calling the Office of the Inspector General, or OIG, and provide them with details. The problem is this: the OIG sends a local team to come over to complete an investigation during business hours. Then, they submit a "report" to the LOCAL VA's Leadership of their findings and recommendations. Then, they leave. Whether that local VA's "Front Office" implements any of the recommendations...God only knows. There is ZERO transparency. Only the secret-highest 5 or 6 at each facility will see the report (along with the OIG). If some past reports made it to the press, it was by an employee who called the press. Those cases are assured of having all feasible recommendations from prior OIG reports implemented.

The person in Arizona that reported the wait lists was about to retire. Thus, he really had no risk of true retaliation by going to the press with his information. Same old same old... Who knows if those wait lists down there were already reported by other employees, but using the internal reporting systems that the VA encourages them to use. The same thing probably took place where NOTHING HAPPENED.

Hopefully, the new leader in DC will change this root of major VA problems. Hopefully the large amounts of money aimed at fixing the VA will bring to light the major weakness at most VA hospitals: unethical upper leaders.

Posted by Another Frontline Clinician
a resident of Palo Alto Hills
on Sep 30, 2014 at 10:39 am

Could not agree more with the posting of "Frontline Palo Alto Clinician". I have worked directly with inpatients at VA Palo Alto for several years. In general, the patients receive good care due to the hard work of nurses, respiratory therapists, medical team doctors/residents, nursing assistants, XRay Techs, lab Techs, pharmacists, Speech Therapists, Physical Therapists, housekeepers and all those who provide services and care at the bedside. And I am fortunate that my direct supervisors remember how difficult direct patient care can be and they truly care about the care delivered to the Veterans.
The same cannot be said about the Administration. We have had our pay cut a couple times in the last 3 years (yes, there are sneaky ways to cut pay to the peons) while Admin folk not only got yearly raises but bonuses to boot. We work short staffed at times which translates without a doubt to less care for the patients. I challenge anyone to work on the units directly with patients for three months and then have the mindset that it's OK to cut those worker's pay. Which believe me, the non nursing pay is low to begin with. It's the prevailing tough job market and folks that are close to retiring that is keeping the front lines filled at VA. And the Veterans are great to work with. I will go the extra mile for any Vet.

I have worked at private hospitals in years passed. I had believed that VA had a different model for patient care. Sadly, they are no different than for profit operations. It's Perception that counts, not Actual Patient Care.

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